Beyond the Affordable Care Act

What are we trying to do by rethinking the ACA?  Perhaps we are seeking an ideologically acceptable ACA, one that the Republicans get credit for rather than the Democrats.   On the other hand, is insurance coverage really the ultimate goal?  I don’t think so.  We want a healthy and educated population that is competitive in the global marketplace.

Health insurance is one way to enable this, but so is a single payer system, e.g., Medicare for everyone.  Health insurance is our apparently preferred choice because that is the incumbent mechanism for paying for healthcare in the US.  A broader question is how do we pay for health, education, and social services that enable a healthy and educated population that is competitive in the global marketplace.

At one extreme, the answer could be that everyone pays for these services themselves.  In other words, everything is privatized and we have the world of Charles Dickens.  Of course, lots of people would not be able to afford health and education, so we would have a large class of people stuck in unhealthy, uneducated poverty.  They would eventually revolt, not just at ballot box, but also by physically attacking the privileged – this has happened many times before (Brook, 2013).

Despite the rhetoric of those who argue for a totally market-based approach, most people accept that governments – federal, state, and local – have to play some role in creating a more equitable situation.  And, at the other extreme, few argue that government should provide all health, education, and social services.  For example, there have been few, if any, calls for nationalizing private institutions of higher education, despite the financial bubble that has emerged in this arena (Rouse, 2016).

So either extreme has a rather limited constituency.  The answer is somewhere in the middle – a public-private “enterprise” that enables a healthy and educated population that is competitive in the global marketplace.  By enterprise, I don’t mean a single organizational entity.  I invoke the enterprise concept to motivate the need to look at the whole system that provides health, education, and social services.

Before suggesting how to find the middle ground needed, two phenomena should be explicitly addressed.  First, people both consume and generate resources, which includes money as well as food, housing, etc.  Health, education, and social services cost money, but people who are healthy, educated, and productive generate money and other resources, a portion of which is taxed by federal, state, and local governments to pay for services.

The Centers for Medicare and Medicaid Services (CMS) work to control the costs of health services.  CMS does not tradeoff these costs versus the resources a healthy population generates.  For example, they have no mechanism to incentivize employers to invest in prevention and wellness programs that will result in healthier employees when they retire and enter the Medicare program, despite the fact that this impact has been repeatedly proven (Rouse & Serban, 2014).

The second phenomenon was identified in an analysis of how value can be estimated for investments in people’s training and education, safety and health, and work productivity (Rouse, 2010).  When the entity investing receives the subsequent returns on these investments, it is often rather straightforward to make the economic case compelling.  However, when the entity investing does not receive the returns, they tend to see the expenditures as costs and try to minimize them.

To deal with the above two phenomena, we need to address the overall enterprise that provides health, education, and social services.  How are delivery, payment, and regulation accomplished in each of these service domains?  The high level of fragmentation in the US across federal, state, and local governments has resulted in a large numbers of silos that see monies spent as costs rather than investments.

This fragmentation affects both the effectiveness and efficiency of these services.  We can use computational simulations with interactive visualizations (Rouse, 2015) to explore ways of breaking down the silos of delivery, payment, and regulation.  I propose that the interactive environment be immersive and enable key stakeholders, which includes almost everybody, to explore the complexity of the overall enterprise.  Ideas such as the sharing of returns on investments – across silos — can be investigated.

Creation of such an environment will require many types of data related to the efficacy and costs of health, education, and social services.  Fortunately, the increasing emphasis on evidence-based policy (Haskins & Margolis, 2015) should provide support for the needed data analytics.  This should, in turn, enable investments in achieving the overarching goal of a healthy and educated population that is competitive in the global marketplace.


Brook, D. (2013). A History of Future Cities. New York: Norton.

Haskins, R., & Margolis, G. (2015). Show Me the Evidence: Obama’s Fight for Rigor and Results in Social Policy. Washington, DC: Brookings.

Rouse, W.B. (Ed.).(2010). The Economics of Human Systems Integration: Valuation of Investments in People’s Training and Education, Safety and Health, and Work Productivity. New York: Wiley.

Rouse, W.B. (2015). Modeling and Visualization of Complex Systems and Enterprises: Explorations of Physical, Human, Economic, and Social Phenomena. Hoboken, NJ: John Wiley.

Rouse, W.B. (2016). Universities as Complex Enterprises: How Academia Works, Why It Works These Ways, and Where The University Enterprise Is Headed. Hoboken, NJ: Wiley.

Rouse, W.B., & Serban, N. (2014). Understanding and Managing the Complexity of Healthcare. Cambridge, MA: MIT Press.

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